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Introduction   

What comes to mind when hearing the phrase abnormal uterine bleeding (AUB)? You may be familiar with uterine bleeding, but what happens when the bleeding is abnormal? What constitutes abnormal bleeding? Especially considering that many cultures stigmatize discussions around uterine health, which makes discussions about uterine bleeding very challenging at times. 

Presently, patients seek guidance and information on various health topics from nurses, including medication education and symptom awareness. The information in this course will serve as a valuable resource for nurses of all specialties, education levels, and backgrounds to learn more about the management of AUB.  

Defining AUB 

What Is AUB? 

Abnormal uterine bleeding (AUB) is a broad clinical term used to define bleeding of the uterus that can be abnormal in non-pregnant women. Abnormal can mean a change in the timing, flow, frequency, or duration of a bleeding episode. For instance, a patient might say that they have a history of bleeding once every 28 days and use two to three pads a day when suddenly they are bleeding every day for two weeks. Another instance can be a patient who has not had any bleeding for a few months and then reports bleeding for a week straight soaking through a pad an hour. AUB is extremely common, affecting up to a third of all women with a uterus and is one of the most common reasons women present to emergency room settings (1,2,3). In general, a normal menstrual cycle occurs every 24-38 days and can last 2-7 days with an expected 5-80 mL of blood loss. Because of the wide range of clinical presentations and causes of AUB, it is important to consider several management options for AUB and clinical care (1,2,3(.  

How and Where Is AUB Diagnosed? 

AUB can be diagnosed in outpatient and inpatient settings. Often, if there is a severe loss of blood, that is most likely seen in emergency rooms or inpatient hospital settings. Other times, AUB can be seen in primary care offices, gynecology offices, and pediatrician offices.  

What are the Clinical Criteria for Diagnosing AUB? 

Clinical criteria for diagnosing AUB are wide and complex. When considering if a patient has AUB, the acronym PALM-COEIN is very useful and internationally recognized. Provided by the International Federation of Obstetrics and Gynecology (FIGO), PALM-COEIN can assist in understanding underlying AUB causes. PALM represents structural possible causes of AUB, whereas COEIN represents non-structural possible causes of AUB. The letters represent the following:  

• P: Polyp 

• A: Adenomyosis 

• L: Leiomyoma 

• M: Malignancy and hyperplasia 

• C: Coagulopathy 

• O: Ovulatory dysfunction 

• E: Endometrial disorders 

• I:  Iatrogenic 

• N: Not otherwise classified 

The actual cause of the AUB will lead to treatment and management options for AUB. For instance, if a patient is suspected to have AUB caused by a uterine polyp, her treatment would not be the same as someone who has AUB caused by a blood disorder. Given the wide range of causes for AUB, it is important to take a detailed clinical history and listen to patient’s concerns to determine the root cause for AUB. Anyone with a uterus is at risk for AUB. Other things to consider for the clinical criteria for AUB include: (1) time of onset (did the bleeding start a few hours ago or has this bleeding been persistent for a few weeks); (2) type of bleeding (bright red, dark, clumpy); and (3) other clinical presentations, such as fever, chest pain, trouble breathing, and changes in urine (1,2,3).   

What Is the Average Cost for AUB Treatment? 

The cost for AUB treatment can significantly vary depending on the type of treatment needed, insurance, dosage, frequency, and other factors. Cost is among a leading reason why many patients cannot maintain their medication and treatment regime (4). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost-effective solutions for your patients.  

Managing AUB  

Obtaining a Relevant Patient History 

As a nurse, one of the most important things you can do for your patients is obtain a relevant patient history. Especially in the case of AUB, given that many things can cause AUB, your role as a nurse in obtaining a relevant patient history can truly be lifesaving and essential for the patient and health care team in addressing her AUB.  

Specific questions to consider when assessing for AUB include: 

1. A detailed menstrual history 
   1. Age of first period (menarche) 
   2. Last menstrual period 
   3. Number of times pregnant  
   4. The number of times delivered a pregnancy.  
   5. Menstrual characteristics 
   6. Menstrual flow, i.e. how much bleeding do you have during your period? 
   7. Menstrual duration, i.e. how many days does your period last? 
   8. Menstrual frequency, i.e. How often do you get your period? 
2. General Bleeding  
   1. Do you ever bleed during or after vaginal sex, including the use of sex toys?  
   2. Have you ever had a history of any sexually transmitted infections (STIs), such as chlamydia or human papillomavirus (HPV)? 
   3. When was the last time you had a Pap smear? 
   4. When was the last time you were screened for STIs?  
3. Medication and Medical History 
   1. What medications are you currently taking, including supplements? 
   2. What health conditions do you currently have? 
   3. What surgeries have you experienced? 
   4. Have you received any blood transfusions in the past year?  
   5. Do you consume any alcohol?  
   6. Do you smoke, such as marijuana, cigarettes, or vape? 
   7. Do you use any other recreational drugs? 
   8. Does anyone in your family have AUB? 
4. General AUB Assessment Questions 
   1. Rate your pain on a scale of 1 to 10. Please tell me where you feel the pain. 
   2. Do you have any trouble peeing or pooping? 
   3. Do you have any changes in sleep patterns?  
   4. Have you had any changes in your weight recently? 
   5. Do you have any trouble breathing, standing, or moving? 
   6. Do you have any vision changes or headaches? 

Additional important questions include:  

• Are you bleeding through more than one pad or tampon an hour? Have you ever bled through more than one pad or tampon an hour?  

• What have you tried to help with your AUB so far? 

• Are you willing to receive a blood transfusion? 

As always, you should obtain vital signs and possibly prep the patient for an abdominal or pelvic exam or both depending on the clinical presentation and health care provider discretion (1,2,3).  

Evaluating AUB 

AUB evaluation can truly vary from person to person. One woman might present to the emergency room with blood on her pants stating she has been bleeding for four hours straight nonstop, whereas another woman might present to the gynecologist’s office for bleeding for four months every day after giving birth. Knowing the wide range of clinical presentations, it is also important to be aware of several possible options for evaluating AUB. AUB evaluation can consist of a physical examination, abdominal examination, pelvic examination, STI testing, Pap smear, ultrasound, pregnancy test, blood work, MRI, and hysteroscopy. 

In some cases, a healthcare provider might also perform an endometrial biopsy (EMB), especially if someone has a history of persistent bleeding. It is also essential to recognize that not all vaginal bleeding is from the uterus. As part of a good evaluation, knowing the source of the bleeding is critical, as vaginal, vulvar, cervical, and uterine bleeding can all have different clinical implications. Most importantly, early intervention and proper diagnosis for AUB are lifesaving, as untreated AUB can lead to severe blood loss, organ damage, and death (1,2,3).  

Pharmacological Methods to Manage AUB 

Depending on the cause of AUB, pharmacological methods can be used. If a patient has severe acute blood loss, IV estrogen or a blood transfusion may be appropriate. If a patient has abnormal uterine bleeding as a result of a thyroid condition, they might receive thyroid medications, such as levothyroxine. Also, if a patient has more complex AUB causes, such as endometriosis, hormonal contraception, and GnRH agonists can be considered as well. Pain medication options, such as NSAIDs, can be offered.  

Non-Pharmacological Methods to Manage AUB 

Depending on the cause of AUB, non-pharmacological methods can be used. Surgeries, such as hysterectomy, are options for women with adenomyosis or those experiencing uterine rupture. Myomectomy, the surgery to remove uterine fibroids, can be an option for women with fibroids as well. When acute AUB has subsided, pelvic floor physical therapy, diet, and stress management can be considered for pain management. 

Nursing Considerations 

What Is the Nurses’ Role in AUB Patient Education and Management? 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of patient care in several healthcare settings. Patients turn to nurses for guidance, education, and support.  

While there are no specific guidelines for the nurses’ role in AUB education and management, here are some suggestions to provide quality care for patients who are experiencing or are suspected to be experiencing AUB. 

• Take a detailed health history. Often, women’s health and AUB are dismissed in health care settings, even in women’s health settings. If a patient is complaining of symptoms that could be related to AUB, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other healthcare professionals, advocate for that patient to the best of your abilities.  

• Review medication history at every encounter. Oftentimes, in busy clinical settings, reviewing health records can be overwhelming. While millions of people take medications, many people take medications that are no longer benefiting from the medication. Ask patients how they are feeling on the medication if their symptoms are improving, and if there are any changes to their medication history.  

• Gather family history. If someone is complaining of symptoms that could be related to AUB, ask if anyone in their immediate family, such as their parent or sibling, experienced similar conditions. 

• Be prepared and willing to answer questions about AUB. Society stigmatizes open discussions of women’s bodies. Many people do not know about the long-term effects of unmanaged AUB or possible treatment options. Be willing to be honest with yourself about your comfort level discussing topics and providing education on AUB. 

• Communicate the care plan to other staff involved for continuity of care. For several patients, AUB management often involves a team of surgeons, specialists, nurses, primary care contacts, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 

• Stay up to date on continuing education related to AUB and uterine health conditions, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other healthcare professionals and educate your patients with the latest information. You can learn more about the latest research on AUB by following updates from evidence-based organizations.  

How can nurses identify if someone has AUB?  

Unfortunately, it is not possible to look at someone with the naked eye and determine if they have AUB. Because of the varied clinical presentation, AUB can vary from person to person. Nurses can suspect if someone has AUB by taking a complete health history, listening to the patient’s concerns, and communicating any concerns to other healthcare professionals (1,2,3). 

What should patients know about AUB?  

Patients should know that anyone with a uterus has the possibility of experiencing AUB. Patients should be aware that if they notice any changes in their bleeding pattern, experience any sharp pains or feel like something is a concern, they should seek medical care. Because of the social stigma associated with uterine health and bleeding, people are hesitant to seek medical care because society has normalized side effects interfering with quality of life and fear of being dismissed by health care professionals.  

However, as more research and social movements discuss AUB more openly, there is more space and awareness for AUB in healthcare. Nurses should also teach patients to advocate for their health to avoid the progression of AUB and possible AUB complications.  

Here are important tips for patient education in the inpatient or outpatient setting.  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 

• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, and menstrual cycle changes (need to identify lifestyle factors that can influence AUB) 

• Tell the health care provider if you notice any changes in your behavior, sleep, sexual health, or weight (possible changes that could hint at fluid retention and bleeding) 

• Tell the health care provider if you have any changes in urinary or bowel habits, such as increased or decreased urination or defecation (potential risk for AUB and other health concerns) 

• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life. 

• Keep track of your bleeding patterns, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 

• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality and self-harm as possible coping mechanisms for AUB) 

• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries. 

• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage your AUB (potential worsening or improving situation) 

Research Findings 

There is extensive publicly available literature on AUB via the National Institutes of Health and other evidence-based journals. If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and healthcare organizations. 

Case Study #1 

Emily is a 19-year-old woman working as a writing assistant. She is a new patient at the OB/GYN office and arrives for her annual exam. She reports that she’s doing OK but has been noticing some changes in her period lately. She states that she’s always had “weird” periods, but this time, she hasn’t had her period for a few months. Today, she woke up, and she was on her period, just in time for her annual. She wants to know what’s causing her irregular periods because her pediatrician told her periods can be irregular as a teenager. Now that she’s an adult, she wants to know what is causing her irregular periods and if this is still normal.  

Case Study #1 Continued 

She mentions that in her family, women tend to have irregular periods, but it’s not something talked about much. Emily agrees to complete the bloodwork and an ultrasound later this week. She’s back in the office a few weeks later, and her thyroid labs indicate possible thyroid issues. Her ultrasound also shows that she might have some uterine fibroids. Emily is interested in learning about the thyroid and fibroids, as she is not familiar with either health condition.  

Emily agrees to follow up with an endocrinologist to further understand her thyroid condition, suspected to be Hashimoto’s. She also wants to know if there is anything she can do about fibroids. She is sexually active and wonders if hormonal birth control would be a good fit for her. 

Conclusion

Abnormal uterine bleeding is a complex health complaint and a sign of a larger issue affecting a woman’s body. Bodies do not randomly or abnormally bleed, so it is important to consider many aspects of someone’s health when assessing and completing an intake for a patient with an AUB complaint. Education and awareness of AUB can influence the lives of many people.  

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